Protomedicatos y lazaretos como instituciones de control de la higiene pública en Chile entre 1879 y 1920 / Colleges of royal physicians and isolation hospitals to control public hygiene in Chile from 1879 to 1920

El presente artículo indaga la aparición de dos instituciones de control de la higiene pública en Chile entre los años 1879 y 1920: los protomedicatos y lazaretos. El objeto de estudio utiliza como caso la presencia de la viruela en La Araucanía. Se abordan las características y contexto que adquirió la instalación de estos dispositivos que permitieron al Estado de Chile operacionalizar el asunto de la higiene pública, lo que interpeló a los profesionales de la salud para avanzar a mayores niveles de perfeccionamiento del ejercicio profesional de la medicina. El Estado liberal positivista de fines de siglo XIX comprendió que el tema de la higiene no era solamente una cuestión de responsabilidad individual, sino que tenía una dimensión social, pública y medio ambiental. No sólo había personas que eran higiénicas, sino también ambientes higiénicos y antihigiénicos. Por tanto, se estudia la higiene, el tribunal del protomedicato, la hoja sanitaria, lazaretos, médicos y vacunadores; quienes estuvieron en permanente tensión con las autoridades del gobierno central debido a los insuficientes recursos proporcionados por el Estado para la atención de los enfermos contagiados con viruela. El estudio se orienta desde una metodología cualitativa con un diseño historiográfico con alcances descriptivos densos. Se han utilizado fuentes primarias y secundarias disponibles en archivos en Chile y Alemania. Los resultados evidencian que la presencia de viruela apareció violentamente en el centro sur de Chile en la segunda mitad del siglo XIX y permaneció en la Araucanía hasta la primera mitad del siglo XX. La violencia con que se desarrolló la viruela generó miedo e incertidumbre afectando a personas de diferentes clases sociales, y tuvo como una de sus causas principales las precarias condiciones de salubridad de la población.

This article investigates the emergence of two institutions for the control of public hygiene in Chile between 1879 and 1920: colleges of royal physicians and isolation hospitals using the case of smallpox in La Araucanía, a region located in the South of Chile. We cover the characteristics and context of these institutions that allowed the State of Chile to address the problems of public hygiene and to prompt health professionals to professionalize the practice of medicine. The liberal positivist state of the late nineteenth century understood that the issue of hygiene was not only a matter of individual responsibility but had a social, public, and environmental dimension. People practiced hygiene alongside the existence of hygienic and anti-hygienic environments. Therefore, hygiene, the royal colleges of physicians, health records, isolation hospitals, doctors, and vaccinators are studied. All of these components of the health care system of the time were in permanent tension with the central government authorities due to the insufficient resources provided by the state for the care of infected patients with smallpox. The study follows a qualitative methodology with a descriptive historiographic design. We used archival primary and secondary sources available in Chile and Germany. The results show that the presence of smallpox appeared ferociously in South-Central Chile in the second half of the 19th century and remained in La Araucanía until the first half of the 20th century. The extent to which smallpox spread, spawning fear and insecurity in people of different social classes, had as one of its leading causes the precarious conditions of health and hygiene of the population.

Entre vacinas, doenças e resistências: os impactos de uma epidemia de varíola em Porto Alegre no século XIX / Between vaccines, diseases, and resistances: the impacts of a smallpox epidemic in nineteenth-century Porto Alegre

Resumo Uma epidemia de varíola que vitimou fatalmente 1% da população de Porto Alegre em 1874 é o tema deste artigo. Com base em ampla pesquisa documental e no cruzamento de informações produzidas por ocasião da morte dos indivíduos atingidos durante o evento, buscamos problematizar as razões pelas quais a varíola apresentou-se em formato epidêmico na cidade. De posse dos mapas de vacinados nos anos anteriores à eclosão da epidemia, pudemos constatar a baixa adesão da população de Porto Alegre ao preventivo, cujo benefício poderia ser ignorado pelos distintos grupos sociais que teciam relações dentro da cidade. Com a chegada de soldados doentes, oriundos de outras localidades, a moléstia se espalhou rapidamente pela cidade, causando a morte de centenas de pessoas.

Abstract This article examines a smallpox epidemic which killed 1% of the population of Porto Alegre in 1874. Through extensive documentary research and comparison with data from those who died, we problematize why smallpox manifested as an epidemic in the city. Maps showing vaccination in the years preceding the outbreak reveal that only low levels of the population of Porto Alegre participated in prevention efforts, and the benefits of these efforts were ignored by the different social groups which were interconnected within the city. As sick soldiers arrived from other places, the disease spread rapidly through the city and caused the death of hundreds of people.

Progression of pathogenic events in cynomolgus macaques infected with variola virus.

Smallpox, caused by variola virus (VARV), is a devastating human disease that affected millions worldwide until the virus was eradicated in the 1970 s. Subsequent cessation of vaccination has resulted in an immunologically naive human population that would be at risk should VARV be used as an agent of bioterrorism. The development of antivirals and improved vaccines to counter this threat would be facilitated by the development of animal models using authentic VARV. Towards this end, cynomolgus macaques were identified as adequate hosts for VARV, developing ordinary or hemorrhagic smallpox in a dose-dependent fashion. To further refine this model, we performed a serial sampling study on macaques exposed to doses of VARV strain Harper calibrated to induce ordinary or hemorrhagic disease. Several key differences were noted between these models. In the ordinary smallpox model, lymphoid and myeloid hyperplasias were consistently found whereas lymphocytolysis and hematopoietic necrosis developed in hemorrhagic smallpox. Viral antigen accumulation, as assessed immunohistochemically, was mild and transient in the ordinary smallpox model. In contrast, in the hemorrhagic model antigen distribution was widespread and included tissues and cells not involved in the ordinary model. Hemorrhagic smallpox developed only in the presence of secondary bacterial infections - an observation also commonly noted in historical reports of human smallpox. Together, our results support the macaque model as an excellent surrogate for human smallpox in terms of disease onset, acute disease course, and gross and histopathological lesions.

Inactivation of poxviruses by upper-room UVC light in a simulated hospital room environment.

In the event of a smallpox outbreak due to bioterrorism, delays in vaccination programs may lead to significant secondary transmission. In the early phases of such an outbreak, transmission of smallpox will take place especially in locations where infected persons may congregate, such as hospital emergency rooms. Air disinfection using upper-room 254 nm (UVC) light can lower the airborne concentrations of infective viruses in the lower part of the room, and thereby control the spread of airborne infections among room occupants without exposing occupants to a significant amount of UVC. Using vaccinia virus aerosols as a surrogate for smallpox we report on the effectiveness of air disinfection, via upper-room UVC light, under simulated real world conditions including the effects of convection, mechanical mixing, temperature and relative humidity. In decay experiments, upper-room UVC fixtures used with mixing by a conventional ceiling fan produced decreases in airborne virus concentrations that would require additional ventilation of more than 87 air changes per hour. Under steady state conditions the effective air changes per hour associated with upper-room UVC ranged from 18 to 1000. The surprisingly high end of the observed range resulted from the extreme susceptibility of vaccinia virus to UVC at low relative humidity and use of 4 UVC fixtures in a small room with efficient air mixing. Increasing the number of UVC fixtures or mechanical ventilation rates resulted in greater fractional reduction in virus aerosol and UVC effectiveness was higher in winter compared to summer for each scenario tested. These data demonstrate that upper-room UVC has the potential to greatly reduce exposure to susceptible viral aerosols. The greater survival at baseline and greater UVC susceptibility of vaccinia under winter conditions suggest that while risk from an aerosol attack with smallpox would be greatest in winter, protective measures using UVC may also be most efficient at this time. These data may also be relevant to influenza, which also has improved aerosol survival at low RH and somewhat similar sensitivity to UVC.

Demographic and clinical factors associated with response to smallpox vaccine in preimmunized volunteers.

CONTEXT: In March 2003, the French Ministry of Health implemented a program on preparedness and response to a biological attack using smallpox as weapon. This program included the establishment of a preoutbreak national team that could be revaccinated against smallpox. OBJECTIVE: To identify demographic and clinical factors associated with vaccination success defined as the presence of a pustule at the inoculation site at day 8 (days 7-9), with an undiluted vaccinia virus derived from a Lister strain among preimmunized volunteers. VOLUNTEERS AND METHODS: From March 2003 to November 2006, we have studied prospectively 226 eligible volunteers. Demographic data were recorded for each volunteer (age, sex, number of previously smallpox vaccinations and date of the last vaccination). Smallpox vaccine adverse reactions were diagnosed on the basis of clinical examination performed at days 0, 7, 14, 21 and 28 after revaccination. RESULTS: A total of 226 volunteers (sex ratio H/F = 2.7) were revaccinated. Median age was 45 years (range: 27-63 yrs). All volunteers completed follow-up. Median number of vaccinations before revaccination was 2 (range: 1-8). The median delay between time of the study and the last vaccination was 29 years (range; 18-60 yrs). Sixty-one volunteers (27%) experienced one (n = 40) or more (n = 21) minor side effects during the 2-14 days after revaccination. Successful vaccination was noted in 216/226 volunteers (95.6%) at day 8 and the median of the pustule diameter was 5 mm (range: 1-20 mm). Size of the pustule at day 8 was correlated with age (p = 0.03) and with the presence of axillary adenopathy after revaccination (p = 0.007). Sex, number of prior vaccinations, delay between the last vaccination and revaccination, and local or systemic side effects with the exception of axillary adenopathy, were not correlated with the size of the pustule at day 8. CONCLUSIONS: Previously vaccinated volunteers can be successfully revaccinated with the Lister strain.

Characterization of UVC light sensitivity of vaccinia virus.

Interest in airborne smallpox transmission has been renewed because of concerns regarding the potential use of smallpox virus as a biothreat agent. Air disinfection via upper-room 254-nm germicidal UV (UVC) light in public buildings may reduce the impact of primary agent releases, prevent secondary airborne transmission, and be effective prior to the time when public health authorities are aware of a smallpox outbreak. We characterized the susceptibility of vaccinia virus aerosols, as a surrogate for smallpox, to UVC light by using a benchtop, one-pass aerosol chamber. We evaluated virus susceptibility to UVC doses ranging from 0.1 to 3.2 J/m(2), three relative humidity (RH) levels (20%, 60%, and 80%), and suspensions of virus in either water or synthetic respiratory fluid. Dose-response plots show that vaccinia virus susceptibility increased with decreasing RH. These plots also show a significant nonlinear component and a poor fit when using a first-order decay model but show a reasonable fit when we assume that virus susceptibility follows a log-normal distribution. The overall effects of RH (P < 0.0001) and the suspending medium (P = 0.014) were statistically significant. When controlling for the suspending medium, the RH remained a significant factor (P < 0.0001) and the effect of the suspending medium was significant overall (P < 0.0001) after controlling for RH. Virus susceptibility did not appear to be a function of virus particle size. This work provides an essential scientific basis for the design of effective upper-room UVC installations for the prevention of airborne infection transmission of smallpox virus by characterizing the susceptibility of an important orthopoxvirus to UVC exposure.

Treating patients with smallpox in the operating room.

Recent events around the world have emphasized the need for health care facilities to prepare to deal with biological threats, including smallpox. At Walter Reed Army Medical Center, Washington, DC, administrators recognized the need for a policy on handling patients with smallpox in the OR and asked a group of students to create a template policy for care of patients with smallpox in need of surgery. This article provides a brief history of smallpox, concerns surrounding smallpox today, and smallpox characteristics with which perioperative personnel should be familiar, as well as a guideline for treating patients in the OR who have smallpox.

Looking back at smallpox.

Smallpox apparently arose through transfer of variola virus to humans from another animal species. By causing a brief infection that required close contact for transmission and engendered solid immunity, the agent was always vulnerable to simple isolation measures. The high replicative fidelity of the viral DNA polymerase limited variola's ability to adapt to humans and preserved orthopoxviral antigenic cross-reactivity, so that vaccinia vaccination protected against smallpox. Host-derived genes encoding immunomodulatory proteins helped shelter viral replication from innate immune responses. Examination of clinical variants suggests that severity of illness was usually determined by host responses during the incubation period. Control of viral replication was aided by early postexposure vaccination and might be strengthened by additional immunological interventions. Massive inflammatory responses were responsible for major features of illness. Some patients with high levels of circulating virus developed hemorrhagic disease resembling septic shock. Continued study of virus-host interactions is needed to defend against genetically modified agents.

Smallpox and smallpox vaccination: neurological implications.

Compulsory vaccination was discontinued in the U.S. in 1972; the world was declared free of smallpox infection in 1980. Since that time, no new smallpox infections have been recognized, and only limited numbers of military and laboratory personnel have been vaccinated. As a result, the majority of the U.S. and the world population have no or diminished immunity to smallpox. Widespread vaccination, beginning with the military and health care workers, is now being undertaken. Public health strategies for immunizing the general population include preexposure voluntary vaccination, case surveillance with ring vaccination, and mass vaccination at the time of attack. Cutaneous complications of vaccination occur in immunosuppressed subjects and in those with atopic dermatitis. Among the most serious complications is postvaccinal encephalomyelitis (PVEM). A related condition, postvaccinial encephalopathy (PVE), may be seen in children less than two years of age. There are no markers to predict who will develop PVEM. In the past, mortality was high, ranging from 10 to 50%. The neuropathology of PVEM suggested an immune-mediated attack on the CNS, but the target of the immune response is unknown. Comprehensive programs are needed for surveillance and confirming case definitions for neurologic complications. Multi-institutional controlled trials of antiviral and immune modulating therapy of PVEM should be considered. Neurologists should be actively involved in the planning process for vaccination programs and in the treatment of neurologic complications.

Case report: pulmonary calcification in smallpox handler's lung.

Smallpox handler's lung was first described by Morris Evans and Foreman in 1963. During the South Wales smallpox outbreak of 1962 several nurses were noted to develop a "flu-like" illness following an exposure to smallpox patients. The late development of pulmonary calcification in one of these nurses, who is now 74 years old, is described.

Smallpox surveillance in Bangladesh: I - Development of surveillance containment strategy.

A major epidemic of Variola major with an estimated 90 000 cases and 18 000 deaths occurred in Bangladesh in 1972. During a 3-year period methods of active surveillance (market search, outbreak investigation, and house-to-house search) were developed to supplement the passive reporting system. The percentage of smallpox cases detected increased from 11.8% in 1972 to 83% in 1975. Together with the implementation of improved methods of outbreak control, smallpox transmission was interrupted in October 1975.